Series Of Mistakes Doomed Flight 592

Contractor, Faa, Valujet Equally At Fault, Panel Says

WASHINGTON — The crash of ValuJet Flight 592 was the culmination of a series of mistakes made by many people.

Unlike in most aviation accidents, there was little the DC-9's flight crew could have done to save the lives of the 110 people on board.

"The ValuJet accident resulted from failures all up and down the line, from federal regulators to airline executives, from the boardroom to workers on the shoproom floor," Jim Hall, chairman of the National Transportation Safety Board, said Tuesday.

Working under that premise, the safety board assigned equal portions of blame to ValuJet Airlines, SabreTech Corp. and the Federal Aviation Administration. The board held the three jointly responsible for allowing deadly oxygen-generating canisters to slip into the jetliner's cargo hold, and for the tragedy that followed.

The canisters, not any electrical or mechanical malfunction, started a raging fire that disabled the plane's flight controls and brought it down, the safety board concluded.

In their probable cause statement, safety board members determined:

- SabreTech, the company hired by ValuJet to maintain its fleet, failed to properly prepare, package, identify and track the oxygen-generating canisters before delivering them to ValuJet on the day of the crash.

- ValuJet failed to closely monitor SabreTech and its operations. By federal law, the airline was responsible for the actions of its maintenance contractor.

- The FAA failed to require fire detection and suppression systems on DC-9s, despite repeated requests from the NTSB after a series of cargo bay fires and accidents.

In fact, the NTSB said, the ValuJet disaster likely would not have happened if the FAA had acted sooner to require the cargo bay fire-fighting systems.

"We know they wouldn't have taken off if they had had a smoke detector in the cargo compartment," said the NTSB's Greg Feith, in charge of the investigation into the ValuJet crash.

Now that the FAA is requiring airlines to install the systems within the next three years, the safety board is recommending that it expedite the process.

"We will immediately initiate a careful review of the board's findings and recommendations," the FAA said in statement released moments after the meeting concluded. "Safety is the highest priority and sole mission of the FAA."

ValuJet officials responded to the NTSB conclusions by continuing to blame SabreTech. Also issuing a prepared statement, the airline said: "(SabreTech) caused an unmarked bomb (mislabeled and deceptively packaged boxes of oxygen generators) to be put on our plane, and, as a result, 110 innocent people lost their lives."

Kenneth Quinn, the attorney representing SabreTech, said his client was happy that ValuJet and the FAA also must share the blame.

"We've admitted our mistakes, while ValuJet has been in a state of denial," he said. "You've got three parties responsible for this accident."

Safety board staff had recommended that ValuJet be assigned only a contributing role in the crash, but board member John Goglia objected, saying federal regulations make clear who is ultimately responsible for a plane's airworthiness.

"The owner-operator is 100 percent responsible for the actions of all its contractors," Goglia said, drawing loud applause from the families of crash victims.

ValuJet Flight 592 took off from Miami International Airport at 2:03 p.m. May 11, 1996, bound for Atlanta. Six minutes into the flight, the crew smelled smoke and attempted to return. The plane crashed in the Everglades 17 miles northwest of the airport.

In all, the safety board made 19 recommendations to the FAA. Many of them centered on the handling of hazardous materials.

Contributing to the accident was the FAA's failure to adequately monitor ValuJet's maintenance program and ValuJet's failure to adhere to its own policy of not carrying hazardous materials, the safety board said.

But the board noted Flight 592 likely would not have crashed if SabreTech employees had installed small plastic safety caps over the firing mechanisms of the oxygen canisters.

The board also criticized Phoenix-based SabreTech for falsifying records. Two employees signed work cards indicating the caps had been installed.